Prevención de la preeclampsia: desde la dieta hasta la aspirina: revisión de la literatura / Prevention of preeclampsia: from diet to aspirin: review of the literature

Introducción y objetivo: Explorar las estrategias de prevención de la preeclampsia que se han propuesto a lo largo de la historia. Método: Revisión narrativa de la literatura sobre la evidencia científica histórica disponible entre 2016 y 2023 acerca de la aspirina y otras estrategias de prevención de la preeclampsia, en bases de datos bibliográficas computarizadas de estudios publicados en revistas indexadas. Resultados: Varios estudios confirman la efectividad de la aspirina para prevenir la preeclampsia en población de alto riesgo, siendo un medicamento con bajo riesgo de complicaciones, con mayor evidencia de efectividad si se inicia antes de las 16 semanas de gestación y con un aparente efecto dependiente de la dosis. Intervenciones como la disminución del consumo de sal, el reposo en cama, la suplementación con ácidos grasos, antioxidantes, L-arginina, zinc o magnesio, y el uso de diuréticos o de inhibidores de la bomba de protones, no han mostrado su utilidad en la prevención de la preeclampsia. Conclusiones: La aspirina a dosis baja es un medicamento seguro en el embarazo y efectivo para prevenir la preeclampsia en población de alto riesgo. Es la estrategia de prevención más ampliamente estudiada a lo largo de la historia para la disfunción endotelial durante la gestación.

Introduction and objective: To explore the different prevention strategies for preeclampsia that have been proposed throughout the history. Method: A narrative review of the historical, scientific evidence available between 2016 and 2021 on aspirin and other preeclampsia prevention strategies in computerized bibliographic databases of studies published in indexed journals. Results: Several studies confirm the effectiveness of aspirin to prevent preterm preeclampsia in high-risk populations, considering this as a safe drug with low risk of complications, with greater evidence of effectiveness when started before 16 weeks of gestation and apparently with a dose-dependent effect. Interventions such as reducing salt intake, bed rest, supplementation with fatty acids, antioxidants, L-arginine, zinc, magnesium, the use of diuretics or proton pump inhibitors have not shown its usefulness in the prevention of high risk preeclampsia patients. Conclusions: Low-dose aspirin is a safe drug in pregnancy and is effective to prevent preeclampsia in high-risk populations. Is the most widely studied throughout history prevention strategy for endothelial dysfunction during pregnancy.

Prevención de la preeclampsia y su relevancia en el contexto latinoamericano: una revisión narrativa / Prevention of preeclampsia and its relevance in the Latin American context: a narrative review

La preeclampsia es un trastorno hipertensivo de la gestación que se evidencia durante las últimas semanas de esta. Globalmente, la preeclampsia es la segunda causa de mortalidad materna. Se estima que su incidencia es de aproximadamente un 16% en los países en vías de desarrollo, y llega a superar el 25% en algunos países de Latinoamérica. Se describirán las principales estrategias de prevención de la preeclampsia y su relevancia en el contexto latinoamericano. La búsqueda de información tuvo lugar en PubMed y BVS para las publicaciones realizadas sobre prevención de la preeclampsia, utilizando la expresión de búsqueda (“Disease Prevention” OR “Primary Prevention”) AND (Pre-eclampsia OR Preeclampsia OR “Pre eclampsia”) AND (“Latin America” OR “Central America” OR “South America” OR Caribbean). En PubMed se encontraron 60 y en BVS 42 resultados que responden a la expresión de búsqueda, y fueron seleccionados 18 artículos que discuten estrategias de prevención de la preeclampsia en Latinoamérica. Con estos resultados, se pueden afirmar que, describir las mejores estrategias de prevención de la preeclampsia en Latinoamérica es una tarea pendiente, pues existe una relativa carencia de publicaciones. En consecuencia, se espera que esta revisión motive futuras investigaciones y sea un recurso útil en la actualización médica.

Preeclampsia is a hypertensive disorder of pregnancy that is evident during the last weeks of it. Globally, preeclampsia is the second leading cause of maternal mortality. It is estimated that the incidence is approximately 16% in developing countries, and reaches over 25% in some Latin American countries. The main strategies for the prevention of preeclampsia and their relevance in the Latin American context will be described. The search for information took place in PubMed and BVS for publications on preeclampsia prevention, using the search expression (“Disease Prevention” OR “Primary Prevention”) AND (Pre-eclampsia OR Pre-eclampsia OR “Pre eclampsia”) AND (“Latin America” OR “Central America” OR “South America” OR Caribbean). In PubMed we found 60 and in VHL 42 results that respond to the search expression, and 18 articles were selected that discuss prevention strategies for preeclampsia in Latin America. With these results, it is possible to afirm that describing the best strategies for the prevention of preeclampsia in Latin America is a pending task, since there is a relative lack of publications. Consequently, it is hoped that this review will motivate future research and be a useful resource in medical updating.

Association of interpregnancy interval and risk of adverse pregnancy outcomes in woman by different previous gestational ages / 中华医学杂志(英文版)

BACKGROUND@#With an increasing proportion of multiparas, proper interpregnancy intervals (IPIs) are urgently needed. However, the association between IPIs and adverse perinatal outcomes has always been debated. This study aimed to explore the association between IPIs and adverse outcomes in different fertility policy periods and for different previous gestational ages.@*METHODS@#We used individual data from China's National Maternal Near Miss Surveillance System between 2014 and 2019. Multivariable Poisson models with restricted cubic splines were used. Each adverse outcome was analyzed separately in the overall model and stratified models. The stratified models included different categories of fertility policy periods (2014-2015, 2016-2017, and 2018-2019) and infant gestational age in previous pregnancy (<28 weeks, 28-36 weeks, and ≥37 weeks).@*RESULTS@#There were 781,731 pregnancies enrolled in this study. A short IPI (≤6 months) was associated with an increased risk of preterm birth (OR [95% CI]: 1.63 [1.55, 1.71] for vaginal delivery [VD] and 1.10 [1.03, 1.19] for cesarean section [CS]), low Apgar scores and small for gestational age (SGA), and a decreased risk of diabetes mellitus in pregnancy, preeclampsia or eclampsia, and gestational hypertension. A long IPI (≥60 months) was associated with an increased risk of preterm birth (OR [95% CI]: 1.18 [1.11, 1.26] for VD and 1.39 [1.32, 1.47] for CS), placenta previa, postpartum hemorrhage, diabetes mellitus in pregnancy, preeclampsia or eclampsia, and gestational hypertension. Fertility policy changes had little effect on the association of IPIs and adverse maternal and neonatal outcomes. The estimated risk of preterm birth, low Apgar scores, SGA, diabetes mellitus in pregnancy, and gestational hypertension was more profound among women with previous term births than among those with preterm births or pregnancy loss.@*CONCLUSION@#For pregnant women with shorter or longer IPIs, more targeted health care measures during pregnancy should be formulated according to infant gestational age in previous pregnancy.

Evaluation of maternal and perinatal outcomes in pregnancy with preeclampsia at Aljala Maternity Hospital

Hypertensive disorders of pregnancy (HDP) accounts for 18% of maternal deaths worldwide, with an estimated number of about 62, 000­77, 000 deaths occur each year. The current study aimed to assess maternal and perinatal outcomes of pregnancies complicated by hypertension in Aljala Maternity Hospital. A retrospective, descriptive, case series analysis for four hundred patients was done on the outcome of hypertensive disorder among pregnant women who admitted and were managed at Aljala teaching hospital with preeclampsia during the years 2019 and 2020. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally, delivery route, indications of cesarean section, fetal and maternal complications were determined. The current finding reported high prevalence of perinatal and maternal mortality among pregnant women with preeclampsia. Moreover, other severe maternal and perinatal complications such as Hemolysis Elevated Liver Enzyme Platelet (HELLP) syndrome, placental abruption, eclamptic fits, as well as low birth weight were also commonly reported. The current study showed early onset of preeclampsia was associated with increased risk of developing adverse maternal-fetal/neonatal outcomes compared to lateonset after 36 weeks. Our findings call for special consideration and close surveillance of those women with early-onset diseases

Efeitos da suplementação do cálcio sobre marcadores da pré-eclâmpsia: ensaio clínico randomizado / Efectos de los suplementos de calcio en marcadores de preeclampsia: ensayo clínico aleatorizado / Effects of calcium supplementation on markers of preeclampsia: randomized clinical trial

Resumo Objetivo Analisar os efeitos da suplementação de cálcio nos marcadores da pré-eclâmpsia ao longo do tempo, comparando o uso de cálcio em alta e baixa dosagem em mulheres grávidas com hipertensão. Métodos Trata-se de ensaio clínico randomizado com três grupos paralelos, placebo controlado, realizado no ambulatório de referência para o pré-natal de alto risco na Região Sul do Brasil, com análise de intenção de tratar e seguimento após quatro e oito semanas. A intervenção consistiu na ingestão de cálcio 500mg/dia, cálcio 1500mg/dia e placebo. Os dados foram analisados segundo um modelo generalizado de estimação de equações mistas adotando α 0,05. Resultados O efeito do cálcio em baixa e alta dosagem na evolução ao longo do tempo foi mantido entre os grupos, mesmo após o ajuste para os fatores de confusão. Houve diferença significativa nos parâmetros analisados na interação tempo e grupo (p <0,000) e diminuição nas médias de 12,3mmHg na PAS, 9,2 mmHg na PAD, 3,2 mg/dl creatinina e 7,2 mg/dl proteinúria para o grupo cálcio 500mg/dia. Os resultados foram semelhantes para o grupo com suplementação máxima. Conclusão O cálcio melhorou o prognóstico vascular em mulheres grávidas com hipertensão ao reduzir os níveis pressóricos e os marcadores da pré-eclâmpsia.

Resumen Objetivo Analizar los efectos de los suplementos de calcio en los marcadores de preeclampsia a lo largo del tiempo, comparando el uso de calcio en dosis altas y bajas en mujeres embarazadas con hipertensión. Métodos Se trata de un ensayo clínico aleatorizado con tres grupos paralelos, placebo controlado realizado en consultorios externos de referencia en el control prenatal de alto riesgo en la Región Sur de Brasil, con análisis de intención de tratar y seguimiento luego de cuatro y ocho semanas. La intervención consistió en la ingesta de calcio 500 mg/día, calcio 1500 mg/día y placebo. Los datos se analizaron de acuerdo con un modelo generalizado de estimación de ecuaciones mixtas adoptando α 0,05. Resultados El efecto del calcio en dosis bajas y altas en la evolución a lo largo del tiempo se mantuvo entre los grupos, inclusive después de los ajustes por los factores de confusión. Hubo diferencia significativa en los parámetros analizados en la interacción tiempo y grupo (p <0,000) y reducción de los promedios de 12,3 mmHg en la PAS, 9,2 mmHg en la PAD, 3,2 mg/dl creatinina y 7,2 mg/dl proteinuria en el grupo calcio 500 mg/día. Los resultados fueron parecidos en el grupo con suplemento en dosis máxima. Conclusión El calcio mejoró el pronóstico vascular en mujeres embarazadas con hipertensión al reducir los niveles de presión y los marcadores de preeclampsia. Registro Brasileiro de Ensaios Clínicos: RBR-9ngb95

Abstract Objective To analyze the effects of calcium supplementation on markers of preeclampsia over time by comparing the use of high- and low-dose calcium in hypertensive pregnant women. Methods This is a randomized clinical trial, placebo controlled, with three parallel groups carried out at the reference outpatient clinic for high-risk prenatal care in the South Region of Brazil, with intention-to-treat analysis and follow-up after four and eight weeks. The intervention consisted of ingesting calcium 500mg/day, calcium 1500mg/day and placebo. Data were analyzed according to a generalized mixed equation estimation model adopting α 0.05. Results The effect of low- and high-dose calcium on evolution over time was maintained between groups, even after adjustment for confounding factors. There was a significant difference in the parameters analyzed in the time and group interaction (p <0.000) and a decrease in the means of 12.3 mmHg in SBP, 9.2 mmHg in DBP, 3.2 mg/dl creatinine and 7.2 mg/dl proteinuria for the 500mg calcium/day group. The results were similar for the maximal supplementation group. Conclusion Calcium improved vascular prognosis in hypertensive pregnant women by reducing blood pressure levels and markers of preeclampsia. Brazilian Registry of Clinical Trials: RBR-9ngb95

Early and late-onset preeclampsia: effects of DDAH2 polymorphisms on ADMA levels and association with DDAH2 haplotypes

Abstract Objective: To examine whether the DDAH2 promoter polymorphisms -1415G/A (rs2272592), -1151A/C (rs805304) and -449G/C (rs805305), and their haplotypes, are associated with PE compared with normotensive pregnant women, and whether they affect ADMA levels in these groups. Methods: A total of 208 pregnant women were included in the study and classified as early-onset (N=57) or late-onset PE (N =49), and as normotensive pregnant women (N = 102). Results: Pregnant with early-onset PE carrying the GC and GG genotypes for the DDAH2 -449G/C polymorphism had increased ADMA levels (P=0.01). No association of DDAH2 polymorphisms with PE in single-locus analysis was found. However, the G-C-G haplotype was associated with the risk for late-onset PE. Conclusion: It is suggested that DDAH2 polymorphisms could affect ADMA levels in PE, and that DDAH2 haplotypes may affect the risk for PE.

Eucommia granules activate Wnt/ß-catenin pathway, and improve oxidative stress, inflammation, and endothelial injury in preeclampsia rats

Purpose: Pre-eclampsia (PE) is a pregnancy-related complication. Eucommia is effective in the treatment of hypertensive disorders in pregnancy, but the specific effects and possible mechanisms of Eucommia granules (EG) in PE remain unknown. The aim of this study was to investigate the effects and possible mechanisms of EG in PE rats. Methods: Pregnant Sprague Dawley rats were divided into five groups (n = 6): the control group, the model group, the low-dose group, the medium-dose group, and the high-dose group of EG. The PE model was established by subcutaneous injection of levonitroarginine methyl ester. Saline was given to the blank and model groups, and the Eucommia granules were given by gavage to the remaining groups. Blood pressure and urinary protein were detected. The body length and weight of the pups and the weight of the placenta were recorded. Superoxide dismutase (SOD) activity and levels of malondialdehyde (MDA), placental growth factor (PIGF), and soluble vascular endothelial growth factor receptor-1 (sFIt-1) were measured in the placenta. Pathological changes were observed by hematoxylin-eosin staining. Wnt/ß-catenin pathway-related protein expression was detected using Western blot. Results: Compared with the model group, the PE rats treated with EG had lower blood pressure and urinary protein. The length and weight of the pups and placental weight were increased. Inflammation and necrosis in the placental tissue was improved. SOD level increased, MDA content and sFIt-1/PIGF ratio decreased, and Wnt/ß-catenin pathway-related protein expression level increased. Moreover, the results of EG on PE rats increased with higher doses of EG. Conclusions: EG may activate the Wnt/ß-catenin pathway and inhibit oxidative stress, inflammation, and vascular endothelial injury in PE rats, thereby improving the perinatal prognosis of preeclamptic rats. EG may inhibit oxidative stress, inflammation, and vascular endothelial injury through activation of the Wnt/ß-catenin pathway in preeclampsia rats, thereby improving perinatal outcomes in PE rats.

How can we reduce maternal mortality due to preeclampsia? The 4P rule

Abstract In low and middle-income countries such as Brazil, most maternal deaths are related to hypertensive complications. Preeclampsia is the leading cause of maternal mortality and morbidity. Significant proportion is associated with the following factors: lack of identification of high-risk women, lack of adequate prevention, difficulty in maintaining a high-risk prenatal follow-up, delayed diagnosis, insecurity and low use of magnesium sulphate, delayed pregnancy interruption and lack of postpartum follow-up of these high-risk cases. Four major actions are proposed to minimize this alarming clinical picture and reduce the mortality rates due to preeclampsia, called the "4 P Rule" (Adequate Prevention - Vigilant Prenatal Care - Timely Delivery (Parturition) - Safe Postpartum). From this simple "rule" we can open a range of important processes and reminders that may help in the guidance of preeclampsia management.

Resultados maternos y fetales en mujeres embarazadas con enfermedad renal crónica basada en la tasa de filtración glomerular / Maternal And Fetal Outcomes In Pregnant Women With Chronic Kidney Disease Based On Glomerular Filtration Rate

Introducción: el embarazo causa adaptaciones en el riñón, tanto en anatomía como en función, para mantener el entorno extracelular, hemodinámico y hormonal. Sin embargo, estos pueden no llevarse a cabo de manera completamente óptima en presencia de enfermedad renal. El objetivo era estudiar la relación entre la enfermedad renal y los resultados maternos de fetal durante el embarazo, asociado con un rechazo por paciente y/o en relación con el tratamiento especializado. Material y métodos: estudio observacional y retrospectivo en una serie de casos, revisando 134 archivos de pacientes embarazadas con cierto grado de enfermedad renal antes del embarazo. Los resultados maternos registrados fueron: enfermedad hipertensiva durante el embarazo, deterioro renal agudo, necesidad de terapia de sustitución renal y en productos: prematuridad, restricción del crecimiento intrauterino, muerte fetal y aborto espontáneo. Resultados: Resultados maternos: tasa media de filtración glomerular (GFR) de 58.23 ml/min, aumento de peso de 7 kg; La preeclampsia fue diagnosticada en 92 mujeres (55 severas). 46 pacientes mostraron lesión renal aguda, 40 se resolvieron conservativamente; 1 requirió diálisis peritoneal y 15 hemodiálisis (con una decisión retrasada un promedio de un mes por rechazo por paciente y/o pariente). La resolución del embarazo fue por cesárea en 111 pacientes; Nacieron 116 productos antes de las 37 semanas de gestación, con un peso promedio de 1910 g, 94 mostraron restricción del crecimiento intrauterino. Conclusión: la enfermedad renal influyó directamente en el mayor número de resultados adversos maternos y fetales cuando se rechazó la atención médica especializada. Existe una correlación entre el ligero estado de Davison con los estados I, II y IIIA de Kdigo en el análisis de correspondencia

Introduction: Pregnancy causes adaptations in the kidney, both in anatomy and function, to maintain the extracellular, hemodynamic and hormonal environment. However, these may not be carried out completely optimally in the presence of kidney disease. The objective was to study the relation between kidney disease and maternal-fetal outcomes during pregnancy, associated with a rejection by patient and/or relative to specialized treatment. Material and Methods: Observational, retrospective study in a series of cases, reviewing 134 files of pregnant patients with some degree of kidney disease prior to pregnancy. Maternal outcomes recorded were: hypertensive disease during pregnancy, acute renal deterioration, need for renal substitution therapy, and in products: prematurity, restriction of intrauterine growth, fetal death and miscarriage. Results: Maternal outcomes: mean glomerular filtration rate (GFR) of 58.23ml/min, weight gain of 7 kg; preeclampsia was diagnosed in 92 women (55 severe). 46 patients showed acute renal lesion, 40 were conservatively resolved; 1 required peritoneal dialysis and 15 hemodialysis (with decision delayed an average of one month by rejection by patient and/or relative). Resolution of pregnancy was by cesarean in 111 patients; 116 products were born before 37 weeks of gestation, with average weight of 1910 g, 94 showed restriction of intrauterine growth. Conclusion: Kidney disease directly influenced the greater number of adverse maternal and fetal outcomes when specialized medical care was rejected. There is a correlation between slight Davison state with states I, II and IIIa of KDIGO in correspondence analysis.

Impactos da covid-19 sobre a gestaçãono desenvolvimento da pré-eclâmpsia: revisão integrativa / Impacts of COVID-19 during pregnancy on the development of pre-eclampsia: an integrative review

Objetivo: Identificar as evidências cientificas acerca da associação da covid-19 e o desenvolvimento de pré-eclâmpsia. Método: Trata-se de uma revisão integrativa, realizada em abril de 2022, mediante acesso às bases de dados: Medical Literature Analysis and Retrieval System Online (MEDLINE) e Portal Regional da Biblioteca Virtual em Saúde (BVS). A partir da utilização dos descritores em saúde: Gestantes, Pré-eclâmpsia e COVID-19. Resultados: Foram incluídos 15 estudos na síntese avaliativa, onde 13 foram provenientes da PubMed (86,6%) e 02 da BVS (13,3%). Quanto ao desenho, seis (40%) estudos foram do tipo relato ou estudo de caso, cinco (33,3%) do tipo revisão sistemática, com destaque para três revisões com meta-análise, dois (13,3%) se tratou estudos observacionais, um (6,6%) estudo descritivo e um (6,6%) estudo de coorte. Conclusão: Foram identificados estudos que associaram o desenvolvimento da pré-eclâmpsia à infecção causada pelo Covid-19, no entanto, outros estudos destacam a detecção de uma síndrome semelhante a pré-eclâmpsia, destacando a necessidade da realização de um diagnóstico diferencial.(AU)

Objective: To identify the scientific evidence on the association between covid-19 and the development of pre-eclampsia. Method: This is an integrative review, carried out in April 2022, through access to the databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) and Regional Portal of the Virtual Health Library (VHL). Using the health descriptors: Pregnant women, Pre-eclampsia and COVID-19. Results: 15 studies were included in the evaluation synthesis, of which 13 came from PubMed (86.6%) and 02 from the VHL (13.3%). In terms of design, six (40%) studies were of the case report or study type, five (33.3%) were of the systematic review type, with emphasis on three reviews with meta-analysis, two (13.3%) were observational studies, one (6.6%) was a descriptive study and one (6.6%) was a cohort study. Conclusion: Studies were identified that associated the development of pre-eclampsia with infection caused by Covid-19, however, other studies highlight the detection of a syndrome similar to pre-eclampsia, highlighting the need for a differential diagnosis.(AU)

Objetivo: Identificar las evidencias científicas sobre la asociación entre el covid-19 y el desarrollo de preeclampsia. Método: Se trata de una revisión integradora, realizada en abril de 2022, a través del acceso a las bases de datos: Medical Literature Analysis and Retrieval System Online (MEDLINE) y Portal Regional de la Biblioteca Virtual en Salud (BVS). Utilizando los descriptores de salud: Embarazadas, Preeclampsia y COVID-19. Resultados: 15 estudios fueron incluidos en la síntesis de evaluación, de los cuales 13 procedían de PubMed (86,6%) y 2 de la BVS (13,3%). En cuanto al diseño, seis (40%) estudios fueron del tipo informe o estudio de caso, cinco (33,3%) fueron revisiones sistemáticas, especialmente tres revisiones con meta-análisis, dos (13,3%) fueron estudios observacionales, uno (6,6%) fue un estudio descriptivo y uno (6,6%) fue un estudio de cohortes. Conclusión: Fueron identificados estudios que asocian el desarrollo de preeclampsia con infección causada por Covid-19, sin embargo, otros estudios destacan la detección de un síndrome semejante a la preeclampsia, enfatizando la necesidad de realizar un diagnóstico diferencial.(AU)

Uso de labetalol frente a nifedipino en la preeclampsia / Use of labetalol vs nifedipine in preeclampsia

Fundamento: La preeclampsia es un estado de vasoconstricción generalizado asociado a la disfunción del epitelio vascular en vez de vasodilatación propia del embarazo, caracterizada por la hipertensión proteinuria a partir de la semana 20, acompañada a veces de edemas; asimismo constituye un peligro de salud para la madre y el feto. El tratamiento clínico tradicional utiliza fármacos antihipertensivos por vía oral, entre los que se mencionan el labetalol y nifedipino de liberación prolongada. Objetivo: Analizar la efectividad del labetalol y del nifedipino como tratamiento antihipertensivo relacionado con preeclampsia. Metodología: Se recurrió a fuentes de consulta encontradas en Google Scholar, Science Direct, SciELO, Pubmed, Medes y Elsevier. De 211 fuentes se seleccionaron 31 de acuerdo con criterios de inclusión y exclusión. Conclusiones: Por consenso se ha determinado que en la mayor parte de fuentes de consulta el nifedipino por vía oral es más efectivo que el labetalol en el tratamiento de la preeclampsia.

Background: Pre-eclampsia is a generalized vasoconstriction state associated with vascular epithelial dysfunction rather than the vasodilation characteristic of pregnancy, characterized by proteinuric hypertension from the 20th week of pregnancy, sometimes associated with edema; it also causes health risks to the mother and fetus. Traditional clinical treatment uses oral antihypertensive drugs, among these labetalol and extended-release nifedipine are included. Objective: To analyze the efficacy of labetalol and nifedipine as an antihypertensive treatment in pre-eclampsia. Methodology: Reference sources found in Google Scholar, Science Direct, SciELO, Pubmed, Medes and Elsevier were used. Out of 211 sources, 31 were selected according to inclusion and exclusion criteria. Conclusions: It has been determined by majority consensus that oral nifedipine is more effective than labetalol in pre-eclampsia treatment.

Tendência temporal de nascidos prematuros no estado de Santa Catarina entre 2011 e 2021 / Temporal trend of premature birth in the state of Santa Catarina between 2011 and 2021

Objetivo: Analisar a tendência temporal de nascimentos prematuros no estado de Santa Catarina entre 2011 e 2021. Métodos: Estudo observacional ecológico de tendência temporal realizado com informações do banco de dados do Sistema de Informação sobre Nascidos Vivos do estado de Santa Catarina (2011-2021), disponibilizado pela Diretoria de Vigilância Epidemiológica. Foram analisados todos os nascidos vivos prematuros segundo o ano de processamento e o local de residência em Santa Catarina (110.422). Foram incluídos os nascidos vivos de gestação com menos de 37 semanas completas. As taxas de nascimentos prematuros foram calculadas proporcionalmente à totalidade de nascimentos e calculadas segundo macrorregião, idade materna, número de consultas do pré-natal, instrução materna e cor de pele. Para o cálculo da tendência temporal, foi utilizada a regressão linear simples, com intervalo de confiança de 95% (p ≤ 0,05). Resultados: A taxa média de nascimentos prematuros no estado de Santa Catarina foi de 10,57%, com tendência estável (p < 0,001). Maiores taxas específicas foram encontradas nas macrorregiões Meio Oeste e Serra e Planalto Norte e Nordeste (11,46%), extremos de idade (10-14 anos e 45-64 anos) e menor escolaridade. Maior número de consultas de pré-natal apresentou taxa de prematuridade menor (7,69%). Tendências crescentes das taxas foram apenas encontradas na macrorregião Grande Oeste, faixa etária materna entre 40-44 anos e entre 4-6 consultas de pré-natal. Conclusão: A tendência da taxa de prematuridade manteve-se estável em Santa Catarina. Baixo número de consultas de pré-natal, extremos de idades e baixa escolaridade mostraram taxas maiores de prematuridade. (AU)

Objective: Analyzing the temporal trend of premature births in the state of Santa Catarina between 2011 and 2021. Methods: Observational ecological temporal trend study carried out with information from the database of the Information System on Live Births in the state of Santa Catarina (2011-2021), made available by the Epidemiological Surveillance Directorate. All premature live births were analyzed according to the year of processing and place of residence in Santa Catarina (110,422). Live births of less than 37 completed weeks were included. The rates of premature births were calculated in proportion to the total number of births and calculated according to macro-region, maternal age, number of prenatal consultations, maternal education and skin color. Simple linear regression was used to calculate the temporal trend, with a confidence interval of 95% (p ≤ 0.05). Results: The average rate of premature births in the state of Santa Catarina was 10.57%, with a stable trend (p < 0.001). Higher specific rates were found in the Midwest and Serra, North Plateau and Northeast macro-regions (11.46%), age extremes (10-14 years and 45-64 years) and lower schooling. A greater number of prenatal consultations had a lower prematurity rate (7.69%). Increasing trends in rates were only found in the Grande Oeste macro-region, maternal age group between 40-44 years and between 4-6 prenatal consultations. Conclusion: The prematurity rate trend remained stable in Santa Catarina. Low number of prenatal consultations, extremes of age and low education showed higher rates of prematurity. (AU)

COVID-19 and Preeclampsia: A Systematic Review of Pathophysiological Interactions / COVID-19 e pré-eclâmpsia: uma revisão sistemática de interações fisiopatológicas

Abstract Objective: To review the literature and synthesize evidence on pathophysiological interactions attributed to the simultaneous occurrence of COVID-19 and preeclampsia. Methods: A systematic review was conducted from November (2021) to January (2022) to retrieve observational studies published on the PubMed, LILACS, SciELO Brazil and Google Scholar databases. The search was based on the descriptors [(eclampsia OR preeclampsia) AND (COVID-19)]. Quantitative studies that pointed to pathophysiological interactions were included. Literature reviews, studies with HIV participants, or with clinical approach only were excluded. The selection of studies was standardized and the evaluation was performed by pairs of researchers. Results: In this review, 155 publications were retrieved; 16 met the inclusion criteria. In summary, the physiological expression of angiotensin-converting enzyme-2 (ACE-2) receptors is physiologically increased in pregnant women, especially at the placental site. Studies suggest that the coronavirus binds to ACE-2 to enter the human cell, causing deregulation of the renin-angiotensin-aldosterone system and in the ratio between angiotensin-II and angiotensin-1-7, inducing manifestations suggestive of preeclampsia. Furthermore, the cytokine storm leads to endothelial dysfunction, vasculopathy and thrombus formation, also present in preeclampsia. Conclusion: The studies retrieved in this review suggest that there is a possible overlap of pathophysiological interactions between COVID-19 and preeclampsia, which mainly involve ACE-2 and endothelial dysfunction. Given that preeclampsia courses with progressive clinical and laboratory alterations, a highly quality prenatal care may be able to detect specific clinical and laboratory parameters to differentiate a true preeclampsia superimposed by covid-19, as well as cases with hypertensive manifestations resulting from viral infection.

Resumo Objetivo: Revisar a literatura e sintetizar evidências sobre interações fisiopatológicas atribuídas à ocorrência simultânea de COVID-19 e pré-eclâmpsia. Métodos: Uma revisão sistemática foi conduzida entre novembro (2021) a janeiro (2022) para recuperar estudos observacionais publicados no PubMed, LILACS, SciELO Brasil e Google scholar. A busca foi baseada nos descritores [(eclâmpsia OR pré-eclâmpsia) AND (COVID-19)]. Estudos quantitativos que apontaram interações fisiopatológicas foram incluídos. Estudos de revisão, com participante HIV e apenas com enfoque clínico foram excluídos. A seleção dos estudos foi padronizada com avaliação por duplas de pesquisadores. Resultados: Nesta revisão, 155 publicações foram recuperadas; 16 preencheram os critérios de inclusão. Em síntese, a expressão fisiológica de receptores da enzima conversora da angiotensina-2 (ECA-2) é fisiologicamente potencializada em gestantes, especialmente no sítio placentário. Os estudos sugerem que o coronavírus se liga à ECA-2 para entrar na célula humana, ocasionando desregulação do sistema renina-angiotensina-aldosterona e da razão entre angiotensina-II e angiotensina-1-7, induzindo manifestações sugestivas de pré-eclâmpsia. Ademais, a tempestade de citocinas conduz à disfunção endotelial, vasculopatia e formação de trombos, também presentes na pré-eclâmpsia. Conclusão: Os estudos recuperados nesta revisão sugerem que a superposição de alterações fisiopatológicas entre a COVID-19 e a pré-eclâmpsia envolve, principalmente, a ECA-2 e disfunção endotelial. Tendo em vista que a pré-eclâmpsia cursa com alterações clínicas e laboratoriais progressivas, a atenção pré-natal de qualidade pode ser capaz de detectar parâmetros clínicos e laboratoriais importantes para diferenciar a pré-eclâmpsia verdadeira sobreposta por COVID-19, bem como os casos que mimetizam a doença hipertensiva consequente à infecção viral.

Ultrassonografia morfológica de primeiro trimestre: importante ferramenta para rastreio de aneuploidias e pré-eclâmpsia / First-trimester morphological ultrasound: important tool for aneuploidy and pre-eclampsia screening

No início do século 20, as altas taxas de mortalidade materna e infantil estimularam o desenvolvimento de um modelo de atendimento pré-natal que mantivesse características parecidas até os dias atuais. Nesse modelo, haveria maior concentração de visitas durante o final do terceiro trimestre de gestação, devido às maiores taxas de complicações nas fases finais da gestação e à dificuldade de prever a ocorrência de resultados adversos durante o primeiro trimestre. Atualmente, a avaliação clínica durante o primeiro trimestre, com auxílio da ultrassonografia e marcadores bioquímicos, pode prever uma série de complicações que acometem a gestação, incluindo cromossomopatias, pré-eclâmpsia, restrição de crescimento fetal, anomalias fetais e trabalho de parto pré-termo.

At the beginning of the 20th century, the high rates of maternal and infant mortality stimulated the development of a model of prenatal care that maintained similar characteristics until the present day. In this model, there would be a greater concentration of visits during the end of the third trimester of pregnancy, due to the higher rates of complications in the final stages of pregnancy and the difficulty in predicting the occurrence of adverse outcomes during the first trimester. Currently, clinical evaluation during the first trimester, with the aid of ultrasound and biochemical markers, can predict a series of complications that affect pregnancy, including chromosomal disorders, preeclampsia, fetal growth restriction, fetal anomalies and preterm labor.

Importancia de la prevención y detección oportuna de la preeclampsia/eclampsia / Importance of prevention and timely detection of preeclampsia/eclampsia

La preeclampsia/eclampsia constituyen una manifestación de la enfermedad hipertensiva que se puede presentar después de la semana 20 del embarazo. Esta tiene la capacidad de generar múltiples complicaciones en la gestante y el feto. Su diagnóstico oportuno y la toma de medidas preventivas ante sus factores de riesgo tienen la potencialidad para reducir la morbimortalidad por esta causa.

Preeclampsia/eclampsia is a manifestation of a hypertensive disease that can occur after the 20th week of pregnancy by generating multiple complications in the pregnant woman and the fetus. Its timely diagnosis and the taking of preventive measures against its risk factors can reduce morbidity and mortality.

Diagnóstico y manejo en primer nivel de atención de preeclampsia posparto de inicio tardío. Reporte de caso / Diagnosis and management of late-onset postpartum preeclampsia at the first level of care. Case report

Introducción: La hipertensión postparto de inicio tardío se presenta desde las 48 horas hasta las 6 semanas postparto, afectando al 2% de los embarazos relacionados o no con antecedentes de hipertensión gestacional. La preeclampsia posparto tiene una incidencia del 5,7% a las 72 horas del parto y está asociada a varios factores maternos como la edad (≥ 35 años), etnia (negra) y obesidad (IMC ≥ 30), presentando mayor riesgo en embarazos múltiples, madres añosas (mayores de 35 años) hogares con bajos ingresos económicos. Los síntomas más frecuentes de esta patología son cefalea, disnea, trastornos visuales y edema periférico.Objetivo: Describir la experiencia en un centro de salud de atención primaria, el manejo de una paciente diagnosticada de preeclampsia posparto de inicio tardío, así como las caracte-rísticas clínicas y factores de riesgo.Presentación del caso: Se presenta el caso de una paciente indígena de 32 años con antece-dente de parto gemelar quien en su control del puerperio a las 72 horas presentó hipertensión arterial, cefalea frontal, edema periférico y proteinuria estableciéndose el diagnóstico de pree-clampsia posparto de inicio tardío. No fue posible la referencia a un segundo nivel de atención por las características culturales de la paciente por lo cual recibió manejo clínico y tratamiento en el primer nivel de atención presentando una evolución favorable sin complicaciones. Conclusiones y recomendaciones: La hipertensión posparto de inicio tardío es una patolo-gía poco frecuente en el puerperio, infradiagnosticada, con complicaciones cardiovasculares a corto y largo plazo, por lo cual su diagnóstico, diferenciación y manejo debe ser óptimo en base a las recomendaciones existentes.

Introduction: Late-onset postpartum hypertension occurs from 48 hours to 6 weeks pos-tpartum, affecting 2% of pregnancies related or not to a history of gestational hypertension. Postpartum preeclampsia has an incidence of 5.7% at 72 hours postpartum and is associa-ted with several maternal factors such as age (≥ 35 years), ethnicity (black) and obesity (BMI ≥ 30), presenting higher risk in multiple pregnancies, elderly mothers (older than 35 years) low-income households. The most frequent symptoms of this pathology are headache, dysp-nea, visual disturbances and peripheral edema.Objective: To describe the experience in a primary care health center, the management of a patient diagnosed with late-onset postpartum preeclampsia, as well as the clinical characte-ristics and risk factors.Case presentation: We present the case of a 32-year-old indigenous patient with a history of twin birth who in her puerperium control at 72 hours presented arterial hypertension, frontal headache, peripheral edema and proteinuria establishing the diagnosis of late-onset pos-tpartum preeclampsia, after which treatment was initiated at the first level of care, making referral difficult due to cultural characteristics. Conclusions and recomendations: Late-onset postpartum hypertension is an infrequent pathology in the puerperium, underdiagnosed, with short and long-term cardiovascular com-plications, so its diagnosis, differentiation and management should be optimal based on existing recommendations

Manejo da hipertensão gestacional no pré-natal: validação de cenário para a simulação clínica / Manejo de hipertensión gestacional: validación de un escenario de simulación clínica / Management of gestational hypertension: Validation of a clinical simulation scenario

Objetivo: desenvolver e validar um cenário e checklist avaliativo para a simulação clínica no ensino em enfermagem, cujo tema é atuação do enfermeiro ante a hipertensão gestacional durante o pré-natal. Materiais e método: trata-se de estudo metodológico, desenvolvido entre janeiro e julho de 2019, seguindo as etapas: overview, scenario, scenario design progression, debriefing e assessment. Participaram do estudo 11 voluntários (4 atores, 2 alunos e 5 juízes). Para a validação, procedeu-se à apresentação do cenário aos juízes como atividade de ensino, com todas as etapas, e, para a análise dos dados obtidos, realizou-se o cálculo do índice de validação de conteúdo (IVC) a partir de respostas dos juízes em uma escala Likert, que avaliou 20 itens sobre o cenário e o checklist. Resultados: classifica-se o cenário validado como de alta fidelidade e de baixa complexidade, e se propõe uma situação em que uma gestante apresentando pressão arterial limítrofe comparece a uma consulta de pré-natal com o enfermeiro. Objetiva-se avaliar se o estudante conhece os critérios diagnósticos da hipertensão gestacional e o manejo adequa-do da situação. O checklist validado se estrutura em três eixos: postura, conhecimento/raciocínio clínico e orientações. Contém destaques nas ações consideradas prioritárias de serem executadas no cenário. O IVC obtido foi de 0,89. Conclusões: o cenário elaborado foi validado pelos juízes. Espera-se que esta seja mais uma ferramenta educacional disponível para o ensino de enfermagem por meio da simulação clínica. Destaca-se que a simulação clínica propõe o ensino centrado no estudante e vem sendo amplamente utilizada na graduação em enfermagem no Brasil e no mundo.

Objetivo: desarrollar y validar un escenario y una lista de verificación para evaluar la simulación clínica en la educación de enfermería, cuyo tema es la actuación de los profesionales de enfermería frente a la hipertensión gestacional durante la atención prenatal. Materiales y método: estudio metodológico desarrollado entre enero y julio de 2019 siguiendo los pasos: resumen, escenario, progresión del diseño del escena-rio, debriefing y evaluación. Once voluntarios (4 actores, 2 estudiantes y 5 jueces) participaron del estudio. Para la validación, se presentó el escenario ante los jueces como una actividad didáctica, con todas las etapas involucradas. Para el análisis de los datos obtenidos, se calculó el índice de validación de contenido (IVC) a partir de las respuestas de los jueces, empleando una escala tipo Likert que evaluó 20 ítems sobre el escenario y lista de verificación. Resultados: el escenario validado se clasifica como de alta confiabilidad y baja complejidad, proponiendo una situación en la que una mujer embarazada asiste a una consulta prenatal con un profesional de enfermería reportando presión arterial limítrofe. El objetivo es evaluar si el estudiante conoce los criterios diagnósticos de hipertensión gestacional y el manejo adecuado de la situación. Por su parte, la lista de verificación validada se estructura en torno a tres ejes: postura, conocimiento/razonamiento clínico y pautas, los cuales señalan las acciones consideradas prioritarias ante el escenario planteado. El IVC obtenido fue de 0,89. Conclusión: el escenario propuesto fue validado, por lo que es de esperar que se constituya en una herramienta disponible para la enseñanza de enfermería a través de la simulación clínica. Se destaca que la simulación clínica propone un enfoque de enseñanza centrado en el estudiante y ha sido ampliamente utilizada en la formación en enfermería a nivel de pregrado en Brasil y en el mundo.

Objective: To develop and validate a scenario and an evaluative checklist for the clinical simulation of the role of nurses in the face of gestational hypertension during prenatal care in nursing education. Materials and method: Methodological study conducted between January and July 2019, following the steps: overview, scenario, scenario design progression, debriefing and assessment. Eleven volunteers (4 actors, 2 students and 5 judges) participated in the study. For validation, the scenario was presented as a teaching activity to selected judge experts, with all the embedded steps involved. Data analysis involved the calculation of the content validation index (CVI) based on the responses by judges, using a Likert scale that evaluated 20 items about the scenario and the checklist. Results: The validated scenario is classified as of high-reliability and low-complexity, proposing a situation in which a pregnant woman attends a prenatal consultation reporting borderline blood pressure to the nursing professional. The objective of this exercise is to assess whether a student knows the diagnostic criteria for gestational hypertension and the appropriate management for this situation. The validated checklist is structured around three axes: posture, knowledge/clinical reasoning, and guidelines, which contain highlights on prioritized actions to be deployed in the face of such a scenario. The CVI obtained was 0.89. Conclusion: The scenario elaborated was validated by the judges. Hence, we expect this becomes another educational tool for nursing education through clinical simulation. It is noteworthy that clinical simulation proposes a student-centered teaching approach that has been widely used in undergraduate nursing education in Brazil and worldwide.

Association between blood pressure during 12-28 weeks gestation and pre-eclampsia: predictive value of blood pressure trajectories constructed by latent class growth modeling / 中华心血管病杂志

Objective: To explore the associations between blood pressure trajectories during pregnancy and risk of future pre-eclampsia in a large cohort enrolling pregnant women at gestational age of ~12 weeks from community hospitals in Tianjin. Latent class growth modeling (LCGM) was used to model the blood pressure trajectories. Methods: This was a large prospective cohort study. The study enrolled pregnant women of ~12 weeks of gestation in 19 community hospitals in Tianjin from November 1, 2016 to May 30, 2018. We obtained related information during 5 antepartum examinations before gestational week 28, i.e., week 12, week 16, week 20, week 24 and week 28. LCGM was used to model longitudinal systolic (SBP) and diastolic blood pressure (DBP) trajectories. For the association study, the predictors were set as SBP and DBP trajectory membership (built separately), the outcome was defined as the occurrence of preeclampsia after 28 weeks of gestation. Results: A total of 5 809 cases with known pregnant outcomes were documented. After excluding 249 cases per exclusion criteria, 5 560 cases with singleton pregnancy were included for final analysis. There were 128 cases preeclampsia and 106 cases gestational hypertension in this cohort. Univariate logistic regression and multivariate logistic regression showed the higher baseline SBP level and DBP level were related with increased risk of preeclampsia. Four distinctive SBP trajectories and DBP trajectories from 12 weeks to 28 weeks of gestation were identified by LCGM. After controlling for potential confounders (baseline BMI, being primipara or not, white blood cell counts, hemoglobin level, platelet counts and alanine aminotransferase level), the OR for SBP latent classification trajectory_ 4 was 4.023 (95%CI: 2.368 to 6.835, P<0.001), and the OR for SBP latent classification trajectory_3 was 1.854 (95%CI: 1.223 to 2.811, P=0.004). Logistic regression showed that: using the DBP latent classification trajectory_1 as the reference group, the OR for DBP latent classification trajectory_4 was 4.100 (95%CI: 2.571 to 6.538, P<0.001), and 2.632 (95%CI: 1.570 to 4.414, P<0.001) for DBP latent classification trajectory_2. After controlling for potential confounders (baseline BMI, being primipara or not, white blood cell counts, hemoglobin level, platelet counts and alanine aminotransferase level), the OR for DBP_traj_4 was 2.527 (95%CI: 1.534 to 4.162, P<0.001), and the OR for DBP_traj_3 was 1.297 (95%CI: 0.790 to 2.128, P=0.303), and 2.238 (95%CI: 1.328 to 3.772, P=0.002) for DBP_traj_2. Therefore, BP trajectories from 12 weeks to 28 weeks identified by LCGM served as novel risk factors that independently associated with the occurrence of preeclampsia. Receiver operating characteristic (ROC) curve analysis showed incremental diagnostic performance by combing baseline blood pressure levels with blood pressure trajectories. Conclusion: By applying LCGM, we for the first time identified distinctive BP trajectories from gestational week 12 to 28, which can independently predict the development of preeclampsia after 28 weeks of gestation.